Care Coordination Services

If you are a GMHBA member with any level of hospital cover and have a diagnosed chronic condition, you may be eligible. Eligibility also depends on your age and hospital admission history, with different programs tailored for varying needs.

Care coordination is a personalised support service offered by GMHBA’s registered nurses to help members, especially those with chronic or complex conditions, to navigate the healthcare system and access the right care at the right time. It typically includes assistance with care planning, service referrals, and support after hospital discharge, aiming to improve health outcomes and reduce hospital readmissions.

No. The Care Coordination Service is included as part of your GMHBA Hospital cover benefits and is provided at no additional cost to eligible members. It is designed to support your recovery without any extra fees.

You will receive personalised care coordination, which includes weekly phone support from a care coordinator who can help organise services such as nursing, physiotherapy, occupational therapy, personal care, meal delivery, domestic assistance and equipment hire as needed.

Support lasts between 2 to 8 weeks, depending on which program you qualify for and your individual care needs.

During your hospital stay, your clinical team (doctor, hospital staff or allied health professional) can refer you to our service. After the referral, a member of the Care Coordination Service team will reach out to learn more about your needs and help create a personalised care plan just for you.

No. Your clinical team will work with you and a GMHBA Care Coordinator to create a care plan tailored to your needs and preferences. Please note that each program includes a minimum requirement of one clinical service.

No. The Care Coordination Service is designed to complement your current care and help coordinate additional support to improve your recovery at home.

Our service includes support options such as personal care and domestic assistance to ensure you have the help you need during your recovery.

Referring your patient to the CCS or Essentials program provides extra support to enhance recovery following hospital admission. Research shows that patients who receive adequate post-hospital care experience fewer complications, improved health outcomes and greater overall wellbeing. These programs bridge the gap between hospital and home, ensuring patients continue their recovery safely with the right level of clinical and personal support.

We care for a wide variety of patients, but the most common groups include:

• Orthopaedic Patients – joint replacements, scopes, fracture management, and post-fall recovery.
• Urology Patients – short-term nursing care, such as leg bag support.
• Respiratory Patients – deconditioning following pneumonia, COPD exacerbation, or chest infections.
• Falls Patients – recovery and reconditioning, with a focus on fall prevention strategies.
• Cardiac Patients – ongoing support following cardiac events or surgery.
• Neurology Patients – recovery post spinal surgery, fractures, or neurological events such as stroke.

Yes. Patients who have completed inpatient rehabilitation and still require ongoing support can be referred to CCS or Essentials. We help them continue their recovery journey at home, providing continuity of care and reducing the risk of setbacks.

No, patients cannot access both CCS and outpatient rehab at the same time. However, CCS can be used as an interim service if your patient is:

• Waiting for wound healing prior to commencing hydrotherapy,
• Unable to attend outpatient rehab due to transport restrictions,
• In need of reconditioning or clinical care before they are ready for outpatient sessions.

Once they are clinically cleared, outpatient rehab can then begin.

Yes, it does. To qualify for CCS Essentials, patients must:
• Be over 18 years of age,
• Have had at least one hospital admission,
• Live with a chronic disease, and
• Require ongoing clinical care (e.g., physiotherapy, nursing, occupational therapy, or personal care).

Yes. We can provide short-term support for up to 4 weeks while your patient awaits their MAC or CHSP setup. During this time, we also help guide the patient and their family through the process, ensuring they receive the right long-term supports. If you assess ongoing personal care will be required ongoing, please submit a My Aged Care referral requesting personal care, providing the patient or family member with the reference numbers.

No. Patients qualify for CCS or Essentials if they have a chronic disease and require clinical care, regardless of whether it is directly related to their recent admission.

No. If your patient already receives domestic assistance through CHSP or HCP, they cannot access this service through CCS. Introducing an additional provider for a service already in place can often cause confusion and reduce continuity of care.

No. To access meals or cleaning support, the patient must also require a clinical component of care such as nursing, physiotherapy, occupational therapy or personal care.